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All right dudes/dudettes, heres my secrets to A line deftness. Follow these carefully and you'll be giving John Tinker a run for the next big Chairman opening. These are proprietary, though, so you have to send me a quarter every time it works. 
1)Make sure you've got everything ready, like UT said.
2) The key to this procedure is positioning. I like the commercially made, blue wrist thingies that put the wrist in perfect extended position. If you dont have these, roll up a blue/green OR towel, and put it under the wrist. Abduct the arm some, on an arm board if you are in the OR, or if you're in holding, take one of those height-adjustable tables, adjust the height to the bed's height, and place the forearm on it.
3) Palpate the pulse, select your site, and put in some intradermal lidocaine. I use a tuberculin syringe. Then take an alcohol swab and push firmly on the wheel to make it flat again, so the area you are looking at is not distorted from the weal (wheal?).
3) We use the Arrow a-line kits. Take the A line and hold it with your thumb and index finger where the END of the catheter (opposite the bevel) meets the rest of the contraption. This gives you dexterity with the bevel.
4) Heres the GREAT trick- making the skin TAUGHT, so the skin doesnt move at all, lets you drive the bevel wherever you want. To accomplish this, place the bottom of your hand at the base of the patient's thumb and pull DISTALLY. At the same time, use your left hand to palpate the pulse, and when you have it, use your left hand to pull the skin PROXIMAL. This effectively makes your site taught.
5) Insert the bevel at your site. I use a pretty steep angle, probably 40 degrees. Pop through the skin, and aim just a little more medial than you're thinking. The artery is usually a little more medial than you think. Push forward.
6) If you get a flash, push just a LITTLE (like 1 mm) further, drop your angle by 10 degrees or so and advance the guidewire. Push the catheter forward with TWISTING motions.
7) Heres a great trick if you cant advance the wire. Pull the wire all the way back, and push the A line THROUGH the artery and pull out the needle, leaving just the catheter there. Now use the black handle on the guidewire and push the guidewire all the way down. Now hold the little black handle with your thumb and forefinger. Put 4X4s under the catheter. With your left hand, pull the catheter back very slowly until pulsatile flow is seen, then pull back justa LITTLE more, like 1mm. Thread the wire through the catheter until you hub it, then advance the catheter, twisting it with every advance. Works 90% of the time when you cant get the wire to thread.
Good luck!
1)Make sure you've got everything ready, like UT said.
2) The key to this procedure is positioning. I like the commercially made, blue wrist thingies that put the wrist in perfect extended position. If you dont have these, roll up a blue/green OR towel, and put it under the wrist. Abduct the arm some, on an arm board if you are in the OR, or if you're in holding, take one of those height-adjustable tables, adjust the height to the bed's height, and place the forearm on it.
3) Palpate the pulse, select your site, and put in some intradermal lidocaine. I use a tuberculin syringe. Then take an alcohol swab and push firmly on the wheel to make it flat again, so the area you are looking at is not distorted from the weal (wheal?).
3) We use the Arrow a-line kits. Take the A line and hold it with your thumb and index finger where the END of the catheter (opposite the bevel) meets the rest of the contraption. This gives you dexterity with the bevel.
4) Heres the GREAT trick- making the skin TAUGHT, so the skin doesnt move at all, lets you drive the bevel wherever you want. To accomplish this, place the bottom of your hand at the base of the patient's thumb and pull DISTALLY. At the same time, use your left hand to palpate the pulse, and when you have it, use your left hand to pull the skin PROXIMAL. This effectively makes your site taught.
5) Insert the bevel at your site. I use a pretty steep angle, probably 40 degrees. Pop through the skin, and aim just a little more medial than you're thinking. The artery is usually a little more medial than you think. Push forward.
6) If you get a flash, push just a LITTLE (like 1 mm) further, drop your angle by 10 degrees or so and advance the guidewire. Push the catheter forward with TWISTING motions.
7) Heres a great trick if you cant advance the wire. Pull the wire all the way back, and push the A line THROUGH the artery and pull out the needle, leaving just the catheter there. Now use the black handle on the guidewire and push the guidewire all the way down. Now hold the little black handle with your thumb and forefinger. Put 4X4s under the catheter. With your left hand, pull the catheter back very slowly until pulsatile flow is seen, then pull back justa LITTLE more, like 1mm. Thread the wire through the catheter until you hub it, then advance the catheter, twisting it with every advance. Works 90% of the time when you cant get the wire to thread.
Good luck!
